Overview: Anatomy Breast Cancer -Definition -Classification -Symptoms -Diagnosis -Treatment Case Write up
Female Breast Anatomy milk-producing glands situated on the front of the chest wall. rest on the pectoralis major muscle - supported by Cooper’s ligaments. Each breast contains 15-20 lobes arranged in a circular fashion. The fat that covers the lobes gives the breast its size and shape. Each lobe comprises many lobules, at the end of which are glands where milk is produced in response to hormones
Ducts Ducts carry Lobes, lobules, milk from bulbs and bulbs aretoward dark area Linked by a of skin in the network of thin center of the tubes (ducts) breast (areola) Ducts join togetherinto larger ducts ending Areola at the nipple, where milk is delivered 4
Lymphatic System Lymph ducts: Drain fluid that carries white bloodLymph node Lymph duct cells (that fight disease) from the breast tissues into lymph nodes under the armpit and behind the breastbone Lymph nodes: Filter harmful bacteria and play a key role inA network of vessels fighting off infection 5
Breast Cancer Cancer that forms in tissues of the breast,usually the ducts (tubes that carry milk tothe nipple) and lobules (glands thatmake milk). It occurs in both men andwomen, although male breast cancer israre. Breast cancer is second only to lungcancer as a cause of cancer deaths inAmerican women 6
EPIDEMIOLOGY: Estimated new cases and deaths from breast cancer in the United States in 2013: New cases: 232,340 (female); 2,240 (male) Deaths: 39,620 (female); 410 (male)(Source: National Cancer Institute)In MALAYSIA: National Cancer Registry (NCR 2006) reported 3,525 female breast cancer cases The most common diagnosed cancer in women & 29.9 % of all new cancers Overall Age-Standardised Incidence Rate: 39.3 per 100,000 population(Source: CPG)
Benign Conditions Fibrocystic changes: Lumpiness, thickening and swelling, often associated with a woman’s period Cysts: Fluid-filled lumps can range from very tiny to about the size of an egg Fibroadenomas: A solid, round, rubbery lump that moves under skin when touched, occuring most in young women
Signs and SymptomsMost common:lump orthickening inbreast. OftenpainlessDischarge Redness or pittingor of skin over thebleeding breast, like the skin of an orange Change in size or contours of Change in color breast or appearance 17 of areola
E, a 49 years old Siamese femalewas admitted electively toHospital Tuanku Fauziah on 2ndMarch 2013 for swelling of leftbreast associated with pain for 2weeks of duration.
HISTORY OF PRESENTING ILLNESS Left sided breast lump since 2010 MVA. Initially size of lump was the size of a 1 cent coin increasing in size for the past few months to a 10 cent coin. Previously, non -tender on palpation till 2 weeks ago No discharge flowing from nipples No skin changes involved Claims occasional pain on sternal edge that radiates to back since breast lump present Loss of appetite for 1 month of duration
HISTORY OF PRESENTING ILLNESS Otherwise:-no clear loss of weight,-no shortness of breath during exertion or resting,-no bone pain, no fever, no upper respiratory tract symptoms,-no abdominal pain-no altered bowel habit No history of any breast disease prior to this. On follow up with KK Kodiang since 2010. Investigations carried out and patient was admitted electively for surgical intervention.
PAST MEDICAL HISTORY1. Bronchial Asthma- On MDI Salbutamol- MDI Betamethasone 2. Acute gastritisDone oesophagogastroduodenoscopy (OGDS) in 2009Diagnosed to have: Gastritis, Helicobacter pylori negative
PAST HOSPITAL ADMISSION -History of lower segment caesarean section (LSCS) done twice -History of appendectomy done -History of intestinal obstruction secondary to adhesion resolved with conservative care (2009) -History of motor vehicle accident with fracture on upper limb (2010)
FAMILY HISTORY No history of breast cancer or any other cancer running in the family No family member or DM, HPT, IHD
SOCIAL HISTORY 4th child from 5 siblings Patient is married with 2 children. Nonsmoker and non-alcoholic. Allergic to seafood.
GENERAL STATUS Head: No abnormality observed Neck: No increased JVP, No enlarged lymph nodes Thorax: Double rhythm no murmur. Vesicular breath sound without added sounds Breast : View localized status Abdomen: Surgical scar seen. Abdomen soft nontender Upper limb: No abnormalities Lower limb: No abnormalities
Localized Status Symmetrical -Size Both breasts are symmetrical in size. -Shape Same shape of breast: Round with no -Position visible lumps seen Skin No visible skin abnormalities. No nodules No ulceration & fungation No texture difference between breast No puckering/dimpling No engorged veins No skin discoloration Nipples & Areolae Nipples present at both sides. Not retracted/ destroyed No accessory nipples Nipples dark brown in color Central in position Areolae smooth with nipple protruded out in the middle No discharge seen Hands by side / Lymph node enlargement not visible Hands slowly raised above head No distended veins No muscle wasting Hand pressed hips No tethering to the skin Unsure if fixated to underlying muscles
LOCALIZED STATUS Lump -Temperature Warm -Tenderness Present on left breast -Site Left upper outer (towards the medial -Size line/border upper and lower) quadrant -Shape 1.5cm x 1.5cm -Surface Round -Margin Smooth -Consistency Well demarcated -Relation to the skin Hard -Relation to underlying muscle Mobile Not fixated Nipple -Retracted nipple Nipple not retracted after release -Feel breast deep to the nipple Could feel the presence of lump -Press for discharge -Appearance None -Character None -Color None Axilla & cervical lymph nodes -Site Not enlarged -Surface - -Consistency - -Tenderness - -Conglumeration -
INVESTIGATIONS FINDINGS FROM PREVIOUS INVESTIGATIONS: Mammography (June 2012) Left sided breast cyst Fine Needle Aspiration Cytology ( 14/02/2013) Atypical suspicious of malignancy (C4 = cells suspicious but probably malignant) LAB INVESTIGATIONS Full blood count Renal profile Liver function test Chest radiograph Electrocardiogram Histopathology examination
REVIEW OF INVESTIGATIONS Full blood count, Renal profile & Liver Function test were mostly in normal range. No significant finding Chest X-ray : Shows mild cardiomegaly ECG: Sinus rhythm. No significant changes
DIAGNOSIS: Breast carcinoma Fibroadenoma Fibrocystic Cyst WORKING DIAGNOSIS: Breast carcinoma Stage 1 (T1N0M0)
PLAN Wide local excision of left breast lump Vital signs monitoring Review investigations For anesthesiology to review for general anesthesia Keep nil by mouth starting from 12 midnight Intra venous drip 4 pint – 2 pint Normal Saline and 2 pint Dextrose 5%
POST OPERATION ASSESSMENT PRESENT STATUS (04-03-2013: 9.30 pm)Vital Signs:Conscious level : Alert and consciousHR : 72x/minRR: 16x/minBP: 122/73 mmHgTemperature : 370CSubjective:Patient complained of pain at the operation site. Pain score 3/10Patient vomited 2 episodes.No fever.Objective:Operation site bandage not soaked.Operation site slightly inflamed. But no signs of pus or active infection.
Assessment:8 hours post wide local excision for Left breast atypia.To give analgesic to ease pain.To give antiemetic for vomiting. Plan:Tablet Paracetamol 1gm QIDCapsule Tramal 50mg TDSTablet Maxolon 10mg Stat & PRNIntra venous drip 4 pint – 2 pint Normal Saline and 2 pint Dextrose 5%Continue vital sign monitoring.To inform if wound soaked